Patterns of Dual Use of Cigarettes and Smokeless Tobacco
among U.S. Males: Findings from National Surveys
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Citation
Tomar, Scott L., Hillel R. Alpert, and Gregory N. Connolly.
2009. Patterns of dual use of cigarettes and smokeless tobacco
among U.S. males: Findings from national surveys. Tobacco
Control 19(2): 104-109.
Published Version
doi:10.1136/tc.2009.031070
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June 17, 2017 9:33:43 PM EDT
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Research paper
Patterns of dual use of cigarettes and smokeless
tobacco among US males: findings from national
surveys
Scott L Tomar,1 Hillel R Alpert,2 Gregory N Connolly2
1
Department of Community
Dentistry and Behavioral
Science, University of Florida
College of Dentistry, Gainesville,
Florida, USA
2
Department of Society, Human
Development, and Health,
Division of Public Health
Practice, Harvard School of
Public Health, Boston,
Massachusetts, USA
Correspondence to
Dr Scott L Tomar, Department of
Community Dentistry and
Behavioral Science, University of
Florida College of Dentistry,
1329 SW 16th Street, Suite
5180, PO Box 103628,
Gainesville, FL 32610-3628,
USA; [email protected]
Received 16 April 2009
Accepted 4 November 2009
Published Online First
11 December 2009
ABSTRACT
Background In the USA, consumption of moist snuff
continues to increase and cigarette manufacturers now
control nearly its entire market. Manufacturers have
developed new products that represent cigarette brand
extension and in test marketing are promoting dual use
of cigarettes and snuff. This study examined patterns of
concurrent use of smokeless tobacco (ST) and cigarettes
among young people and adults in the USA just before
cigarette companies’ control of the nation’s ST market.
Methods Data were drawn from four US nationally
representative surveys. Stratified analyses applied
sampling weights and accounted for the complex sample
designs.
Results Cigarette smoking was substantially more
prevalent among young males who used ST than among
those who did not. Among adult males, those who
smoked daily were less likely than others to have used
snuff every day. Men who used moist snuff daily had the
lowest prevalence of daily smoking, but the prevalence
of daily smoking was relatively high among men who
used moist snuff less than daily. Unsuccessful past-year
attempts by daily smokers to quit smoking were more
prevalent among non-daily snuff users (41.2%) than
among those who had never used snuff (29.6%).
Conclusions Although dual daily use of ST and
cigarettes is relatively uncommon in the USA, concurrent
ST use is more common among adolescent and young
adult male smokers than among more mature tobacco
users. Among adult males, daily smoking predominates
and non-daily ST use is very strongly associated with
current smoking. Adult male smokers who also use ST
daily tend to have relatively high levels of serum cotinine
and high prevalence of a major indicator for tobacco
dependence.
BACKGROUND
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104
Smokeless tobacco (ST) products include chewing
tobacco, dry snuff and moist snuff. Consumption
of chewing tobacco in the USA decreased from 47
million to 36 million pounds, and dry snuff from
3.5 million pounds to 2.2 million pounds from 2000
to 2006.1 However, during the same time period,
consumption of moist snuff increased from 61.5
million pounds to 77.4 million pounds.1 Recently,
cigarette and ST manufacturers have introduced
a drier form of moist snuff called snus (20% moisture content vs 50% in traditional moist snuff),
which is packaged in a pouch, often flavoured, and
placed in the upper lip to reduce spitting. Snus has
gained popularity among boys and men in Sweden,
among whom its prevalence of use is greater than
cigarette smoking.2
For decades, the US ST market was dominated
by a small number of companies that sold only ST
and had no financial interest in selling cigarettes.
That situation changed with the acquisitions of the
Conwood Company in 2006 by Reynolds American, Inc3 and the US Smokeless Tobacco Company
(USSTC) in 2008 by Altria Group, the parent
company for Philip Morris USA.4 Cigarette
companies have also introduced new ST products,
including moist snuff and snus, sold under cigarette
brand names such as Marlboro and Camel. The
recent entry by the cigarette industry into the US
ST market, and expanded promotion of existing and
new ST products, may have far-reaching public
health implications. This new development has the
potential to encourage increased ST use among
young people and dual use of ST and cigarettes
among smokers, while slowing reductions in
smoking prevalence and undermining cessation.
Few studies have been conducted regarding the
extent of dual use of ST and cigarettes in the
USA,5e8 and none has examined detailed patterns
across multiple population-based data sources. The
purpose of this study was to examine patterns of
concurrent use of ST and cigarettes among young
people and adults in the USA. The data were
primarily collected before the recent acquisitions of
the US ST companies by cigarette manufacturers,
and the analyses therefore may be viewed as
a baseline measure of the extent of dual product use
just before the entry of the major cigarette companies into the nation’s ST market. The analysis
focused specifically on snuff, where possible. It also
analysed levels of serum cotinine and markers of
nicotine addiction such as time to first cigarette
after waking among exclusive smokers and dual
product users. Because use of ST in the USA is
relatively rare among females, all analyses in this
study were limited to males.
METHODS
Data sources
Data for this study were drawn from four US
nationally representative surveys. We include four
data sources because each survey has its particular
strengths and limitations and no single data source
adequately covers the full range of ages and variables related to dual use of cigarettes and ST. For
example, the Current Population Survey Tobacco
Use Supplement provides extensive detail on
tobacco use, but is not anonymous and does not
include people under age 16. School-based surveys
such as the Monitoring the Future Study and the
National Youth Tobacco Survey are anonymously
Tobacco Control 2010;19:104e109. doi:10.1136/tc.2009.031070
Research paper
administered and reach younger people but provide more limited
detail on pattern of tobacco use. In addition to self-reported
data, the National Health and Nutrition Examination Survey
collects biological specimens that enables measurements such as
serum cotinine levels, but has a limited sample size for subgroup
analyses. These surveys use different sampling schemes, methodologies and questions to collect data on tobacco use and other
variables included in this study. The sources and variables
examined are briefly summarised below.
Current Population SurveydTobacco Use Supplement
The US Bureau of the Census and the US Bureau of Labour
Statistics have conducted the Current Population Survey (CPS)
for more than 50 years to assess employment in the USA (US
Census Bureau 2006 http://www.census.gov/prod/2006pubs/
tp-66.pdf). The sample is drawn from the US civilian, noninstitutionalised population age 15 years or older. Data are
collected monthly through household interviews. Questions on
tobacco use were added as a National Cancer Institute-sponsored
Tobacco Use Supplement (TUS) to the monthly CPS in May and
August 2006 and January 2007, which are the most recent data
available at this time. Data for those 3 months were combined
and used to produce national estimates. Although CPS includes
both self-reported and proxy-reported data, analysis in this study
included only self-reported data. Further information on the CPSTUS is available at: http://riskfactor.cancer.gov/studies/tus-cps/.
Monitoring the Future Survey
Supported by grants from the National Institute on Drug Abuse,
the University of Michigan’s Institute for Social Research has
surveyed nationally representative samples of high school seniors
in the spring of each year since 1975 as part of the Monitoring the
Future (MTF) Survey.9 Beginning in 1991, surveys also have been
conducted among 8th- and 10th-grade students. Multistage
sampling designs were used to randomly select students in public
and private schools within the 48 contiguous states. Selfadministered questionnaires were distributed to students in
classrooms by trained personnel, and standardised procedures
were followed. This report uses MTF Survey data from public use
data tapes for 2005 and 2006. A detailed description of the MTF
survey is available elsewhere.9
National Health and Nutrition Examination Survey
The National Health and Nutrition Examination Survey
(NHANES) is a programme of studies conducted by the National
Center for Health Statistics to assess the health and nutritional
status of adults and children in the USA. As part of the NHANES,
venepuncture is performed to collect a blood sample from each
participant. The blood samples are subsequently assayed for
a wide range of biochemical substances, including cotinine,
a major metabolite of nicotine and a biomarker for nicotine
exposure. The NHANES is designed to be representative of the
civilian, non-institutionalised US population. The analyses in this
study included data from 1999 to 2006 for men aged 20 years and
older. Further details on NHANES are available at http://www.
cdc.gov/nchs/nhanes.htm.
National Youth Tobacco Survey
The National Youth Tobacco Survey (NYTS) has been conducted
by the Centers for Disease Control and Prevention since 1999 to
provide estimates of current use of tobacco products among US
middle school and high school students. The NYTS uses anonymous, self-completed survey instruments administered to
students in a multi-stage probability sample of public and private
Tobacco Control 2010;19:104e109. doi:10.1136/tc.2009.031070
schools and classes. Further information on the NYTS is available
at: http://www.cdc.gov/tobacco/data_statistics/surveys/NYTS/
index.htm. This study included data from the 2006 NYTS.
Analysis
Each of the datasets was analysed for a number of parameters
related to dual use of smokeless tobacco and cigarettes, including
< The prevalence of smoking, by smokeless tobacco use status
< The prevalence of smokeless tobacco use status, by smoking
status
< Number of cigarettes smoked per day by daily smokers, by
smokeless tobacco use status
< Sociodemographic characteristics of dual users
< Indicators of nicotine addiction, by smoking and snuff use
status
< Interest and attempts to quit smoking among daily smokers,
by snuff use status
< Biochemical markers of nicotine exposure, by smoking and
snuff use status.
Most analyses involved bivariate contingency tables, generally
stratified by demographic characteristics such as age or grade in
school. All datasets included in this study used complex sample
designs and applied sampling weights to account for differential
probabilities of selection and participation. Therefore, all statistical analyses were conducted on weighted data by using SAS and
SUDAAN software packages. p Values are reported for some
specific comparisons of means or proportions, and we reported
standard errors for estimated means and proportions to allow
readers to calculate confidence intervals for those estimates.
RESULTS
Young people
Patterns of dual use
Based on the 2004 NYTS, 7.6% of male middle school students
and 21.0% of male high schools students smoked on at least one
of the 30 days preceding the survey (table 1). The prevalence of
cigarette smoking was substantially higher among young males
who used ST than among those who did not. For example, in the
2004 NYTS, 69.1% of boys in middle school who used ST every
day also smoked during the preceding 30 days; 53.8% smoked
every day. The pattern was similar for male high school students
in the NYTS: about 60% of those who used ST in the past
30 days also smoked, compared to 17% of those who did not use
ST. Although there were relatively few high school males in any
grade who used STon a daily basis, 8th graders in the 2005e2006
MTF Survey (data not shown) who used ST daily had a much
higher prevalence of smoking one-half pack of cigarettes or more
per day (10.8%) than did those who did not use ST at all (1.3%).
The pattern was even more pronounced among 10th grade male
students: 22.7% of daily ST users also smoked one-half pack of
cigarettes or more per day, compared with 8.8% of less-than-daily
ST users and 1.7% of those who did not use ST at all. Males in
12th grade who used STon a daily basis did not differ appreciably
on the prevalence of smoking one-half pack or more per day
(22.8%) from those who used ST but less than daily (25.9%), but
the prevalence of smoking one-half pack of cigarettes or more per
day was about five times greater among ST users than among
non-users (4.7%).
Based on the 2004 NYTS, 3.1% of male middle school
students and 9.5% of male high school students used ST on at
least one of the 30 days preceding the survey (table 2). STuse was
substantially higher among young males who smoked than
among non-smokers. For example, 27.7% of male middle school
students who smoked daily during the preceding 30 days also had
105
Research paper
Table 1 Cigarette smoking within the 30 days preceding the survey, by
number of days of smokeless tobacco use within the preceding 30 days
Number of
days used
smokeless
tobacco in
the
preceding
30 days
Middle school*
All 30 days
1e29 days
0 days
Total
High schooly
All 30 days
1e29 days
0 days
Total
Number of days smoked cigarettes of
preceding 30 days
Smoking status
All 30 days
Current
daily
Current
some
day
Former
Never
%
SE
%
SE
%
SE
%
SE
7.3
37.4
29.1
14.9
16.0
0.9
2.5
0.7
0.2
0.2
7.7
7.3
6.3
3.5
3.8
1.0
1.4
0.4
0.1
0.1
34.9
22.7
36.7
24.5
25.6
1.7
2.1
0.8
0.2
0.2
50.0
32.6
27.9
57.1
54.5
1.8
2.4
0.7
0.2
0.2
1e29 days
0 days
Unweighted
sample size
%
SE
%
SE
%
SE
42
140
6327
6509
53.8
9.3
0.7
1.2
8.1
3.0
0.1
0.2
15.3
39.3
5.5
6.4
6.5
4.3
0.4
0.5
30.9
51.3
93.9
92.4
8.6
5.1
0.5
0.6
105
348
5804
6257
32.1
26.3
5.4
7.6
5.1
2.9
0.6
0.7
27.8
32.7
11.6
13.5
5.0
2.7
0.7
0.7
40.2
41.0
83.0
79.0
6.1
3.5
1.0
1.2
Male middle school students (grades 6e8) and high school students (grades 9e12).
National Youth Tobacco Survey, 2004.
*c2 test of independence between smokeless tobacco use and smoking ¼ 39.65 (df ¼ 4),
p < 0.00001.
yc2 ¼ 55.51 (df ¼ 4); p < 0.00001.
used ST during that time period, compared to 1.6% of those who
had not smoked during the preceding 30 days. Differences
between lighter smokers and heavier smokers in the prevalence of
ST use were more pronounced among students in higher grades
than in lower grades. For example, in grade 8 in the 2006 MTF
Survey, 24.8% of males who smoked at least one-half pack of
cigarettes per day also used ST during the preceding 30 days,
while in grade 12 the corresponding prevalence was 40.8% (data
not shown).
Adults
Patterns of dual use
Among males age 25 years or older in the 2006e2007 CPS-TUS,
16.0% smoked daily and 3.8% smoked on a non-daily basis
(table 3). Men who used snuff on a daily basis had the lowest
prevalence of daily smoking (7.3%), compared to 14.9% of men
who had never used snuff, 37% of those who used snuff but less
than every day and 29.1% of former snuff users.
Among men age 25 years or older in the 2006e2007 CPS-TUS,
0.6% of daily smokers also used snuff every day, compared to
Table 2 Smokeless tobacco (ST) use within the 30 days preceding the
survey, by number of days of cigarette smoking within the preceding
30 days
Number of
days
smoked
cigarettes
in the
preceding
30 days
Middle school
All 30 days
1e29 days
0 days
Total
High school
All 30 days
1e29 days
0 days
Total
Number of days used ST of preceding 30 days
Snuff use status
Unweighted
sample size
Current daily
Current some day
Former
Never
Total
1100
539
5989
59665
67293
Current Population Survey Tobacco Use Supplement 2006e2007.
2.9% of non-daily smokers, 1.9% of former smokers and 1.3% of
never smokers (table 4).
Selected sociodemographic characteristics of male daily
smokers aged 25 years or older, by snuff use status, were analysed
in the 2006e2007 CPS-TUS (data not shown). Daily dual
product users were younger (mean ¼ 42.45 years) than daily
smokers who never used snuff (mean ¼ 46.36 years; p ¼ 0.005).
Daily smokers who also used snuff on some days were
significantly younger (mean ¼ 38.58 years) than daily dual users
(p ¼ 0.02), former users (mean ¼ 41.68 years; p ¼ 0.002) and
never users (p < 0.00001). Nearly all dual product users were
white and were not of Hispanic ethnicity. Dual product use was
most common in the southern region of the USA, including
53.6% of daily smokers who also used snuff daily and 45.2% of
those who used snuff occasionally, compared to 38.0% of male
daily smokers who had never used snuff. Dual product users also
were over-represented in non-metropolitan areas. Among male
daily smokers, the prevalence of concurrent snuff use was highest
in Wyoming (11.8%), North Dakota (6.5%), Arkansas (5.9%) and
West Virginia (5.6%) (data not shown).
Serum cotinine levels
Data on serum cotinine levels among male daily smokers were
derived from the 1999e2006 National Health and Nutritional
Examination Survey. Although the estimates are based on relatively small sample sizes, daily smokers who also used ST every
day smoked about the same mean number of cigarettes per day as
did daily smokers who used ST on some days or had never used
ST (table 5). Daily dual product users had a significantly higher
mean serum cotinine level than daily smokers who used ST on
some days or never used it.
Smoking dependence and cessation
Table 6 presents data on a key indicator of tobacco dependence10
from the 2006e2007 CPS-TUS among men who smoke daily, by
ST use status. Smoking within 30 minutes of waking was most
All 30 days
1e29 days
0 days
Unweighted
sample size
%
SE
%
SE
%
SE
79
443
5987
6509
26.3
1.4
0.2
0.6
6.0
0.6
0.1
0.1
20.0
15.7
1.4
2.6
5.5
2.3
0.3
0.4
53.7
82.9
98.4
96.9
7.9
2.4
0.3
0.4
390
873
4994
6257
9.6
4.7
1.2
2.3
1.9
1.0
0.3
0.4
25.2
17.6
3.8
7.2
2.8
1.9
0.5
0.7
65.2
77.7
95.1
90.5
3.3
2.4
0.6
1.0
Male middle school students (grades 6e8) and high school students (grades 9e12).
National Youth Tobacco Survey, 2004.
106
Table 3 Smoking status of males aged 25 years or older, by snuff use
status
Table 4 Snuff use status of males aged 25 years or older, by cigarette
smoking status
Snuff use status
Smoking status
Unweighted
sample size
Current daily
Current some day
Former
Never
Total
10802
2403
19125
34963
67293
Current
daily
Current
some day
Former
Never
%
SE
%
SE
%
SE
%
SE
0.6
2.9
1.9
1.3
1.4
0.08
0.4
0.1
0.07
0.05
1.7
1.4
0.6
0.4
0.7
0.1
0.3
0.07
0.04
0.04
14.1
12.8
11.2
4.0
7.8
0.4
0.8
0.3
0.1
0.1
83.6
82.9
86.3
94.3
90.1
0.4
0.9
0.3
0.1
0.1
Current Population Survey Tobacco Use Supplement 2006e2007.
Tobacco Control 2010;19:104e109. doi:10.1136/tc.2009.031070
Research paper
Table 5 Mean number of cigarettes smoked per day and mean serum
cotinine level among male daily cigarette smokers* aged 20 years or
older, by smokeless tobacco use status
Smokeless
tobacco
use
Unweighted
sample size
Cigarettes per
day
Serum cotinine
(ng/ml)
Mean
SE
Mean
SE
Every day
Some days
Former
Never
Total
11
22
32
761
826
17.06
17.75
22.69y
17.50
17.73
3.79
1.62
1.70
0.57
0.51
344.20z
215.79
276.74
241.51
244.72
40.02
22.69
22.54
4.90
4.51
National Health and Nutrition Examination Survey, 1999e2006.
*Excludes persons using cigars, pipes, or nicotine replacement pharmacotherapy.
ySignificantly greater than some day smokeless tobacco use or never used smokeless
tobacco (p # 0.006).
zSignificantly greater than some day smokeless tobacco use (p¼ 0.01) or never used
smokeless tobacco (p¼ 0.02).
prevalent among daily smokers who also used ST daily (74.5%)
and least prevalent among daily smokers who never used
smokeless tobacco (63.8%).
Based on the 2006e2007 CPS-TUS, 30.0% of male daily
smokers aged 25 years or older quit smoking for at least 1 day
within the 12 months preceding the survey. Past-year quit
attempts were more prevalent among non-daily snuff users
(41.2%) than among daily smokers who had never used snuff
(29.6%) That group also expressed a significantly greater
Table 6 Prevalence of selected indicators of addiction and quit
attempts among of male daily smokers aged 25 years, by snuff use status
Indicator of addiction or quitting/snuff Unweighted Percentage
use status
sample size or mean
SE
First cigarette #30 minutes after waking
Current daily
Current some days
Former
Never
Total
Quit smoking one or more days in past
12 months
Current daily
Current some days
Former
Never
Total
Seriously considering quitting smoking
within next 6 months
Current daily
Current some days
Former
Never
Total
Degree of interest in quitting smoking*
Current daily
Current some days
Former
Never
Total
p Value
0.005
75
197
1623
8566
10461
74.5
68.7
68.4
63.8
64.6
5.6
4.1
1.4 y
0.6
0.6
0.05
75
198
1638
8816
10727
27.9
41.2
31.1
29.6
30.0
6.3
4.3 z,x
1.4
0.6
0.5
0.0014
74
196
1600
8642
10512
36.5
48.0
44.8
39.2
40.2
6.5
4.3 {
1.5 **
0.6
0.6
<0.0001
0.41
0.26 yy
0.10 zz
0.04
0.04
75
197
1628
8637
10537
5.21
5.90
5.58
5.18
5.25
Current Population Survey Tobacco Use Supplement 2006e2007.
*Respondents were asked to rate their level of interest in quitting smoking on a scale from
1e10, where 1 ¼ not at all interested and 10 ¼ extremely interested.
ySignificantly higher than for those who never used snuff, p¼ 0.0026.
zSignificantly higher than for those who formerly used snuff, p¼ 0.025.
xSignificantly higher than for those who never used snuff, p¼ 0.0072.
{Significantly higher than for those who never used snuff, p¼ 0.046.
**Significantly higher than for those who never used snuff, p¼ 0.0005.
yySignificantly higher than for those who never used snuff, p¼ 0.0067.
zzSignificantly higher than for those who formerly used snuff, p¼ 0.0001.
Tobacco Control 2010;19:104e109. doi:10.1136/tc.2009.031070
degree of interest in quitting than did daily smokers who did not
use snuff.
DISCUSSION
Based on data from four large, US nationally representative
surveys of young people or adults, the association between
smokeless tobacco use and cigarette smoking is complex. The
prevalence of smoking is generally quite high among men who
use snuff on a less-than-daily basis and among former snuff
users, while the prevalence of smoking is relatively low among
men who use snuff every day. The pattern is quite different for
young people: the prevalence of daily smoking is very high
among male students in middle school and high school who use
smokeless tobacco. This pattern is consistent with findings from
an earlier US nationally representative prospective cohort study,
which found that early dual users largely moved towards cigarette smoking later in life.11
A number of indications in this study reflect a potentially
troubling pattern of smoking associated with non-daily ST use:
‘some day’ snuff users are more likely to be current daily smokers
than any other group, and daily smokers who also use snuff on
some days expressed greater interest in quitting smoking than
the other groups but were more likely than any other group to
have had unsuccessful quit attempts in the preceding year. This
pattern of tobacco use may represent a partial substitution of
smoking and a prolonging of dependence. Conversely, it is
possible that smokers who have had unsuccessful quit attempts
subsequently turned to snuff as a cessation strategy. Understanding the reasons for dual use clearly requires further research.
Although dual daily use of ST and cigarettes is relatively
uncommon, that pattern is more common among adolescents
and young adults than among more mature tobacco users.
Although male dual daily users tend to smoke fewer cigarettes per
day than male daily smokers who do not use snuff or use it less
than daily, they tend to have the highest levels of serum cotinine
and exhibit among the most prevalent indicator of dependence.
Interestingly, daily smokers who also used snuff on
a non-daily basis had serum cotinine levels that were essentially
equivalent to those of daily smokers who never used snuff,
although there was no significant difference in the number of
cigarettes they smoked per day. It is not known whether that
pattern reflects their infrequency of snuff usage, greater
compensation among smokers whose only source of nicotine
was cigarettes, biological factors such differences in nicotine
metabolism, or the relatively imprecise estimates that resulted
from small sample sizes.
The landscape of tobacco use is rapidly changing in the USA.
Per capita cigarette consumption has reached its lowest point in
more than 60 years,12 smoking among high school students is at
its lowest level since tracking began9 and smoke-free indoor
regulations continue to proliferate.13 14 However, sales of moist
snuff in the USA continue to increase each year.1 In stark
contrast to the situation that existed in the USA until 2006,
when almost the entire smokeless tobacco market was controlled
by companies that did not manufacture cigarettes, cigarette
manufacturers now control virtually the entire US snuff market.
There is no indication that the major tobacco companies are
planning to abandon cigarette manufacturing; on the contrary,
they appear to be positioning traditional and new types of ST
products as complements and as situational substitutes for
cigarettes.15 The most recently available data suggest that dual
product use is primarily concentrated in regions and subpopulations of the USA where ST use has been relatively prevalent for
many yearsdfor example, young males in southern and
107
Research paper
Appalachian states, northern plain states and in non-metropolitan areas. With tobacco companies such as Reynolds American,
Philip Morris USA, Liggett and Lorillard focusing their test
marketing efforts on areas with large college student populations, such as Columbus, Ohio and Austin, Texas and large urban
areas with recent smoke-free indoor air laws, such as Indianapolis, Portland and Orlando,16e18 dual use of cigarettes and ST
may become more prevalent in other regions.
Our findings are consistent with other US studies on dual use
of ST and cigarettes. An earlier analysis of 1998 National Health
Interview Survey data also found a high prevalence of smoking
among men who used ST on some days, and indications that
some men were using ST as a way to quit smoking.5 Similar to
our findings, previous analyses of the 2002 and 2004 National
Youth Tobacco Surveys found that a large proportion of young
people who smoked also used other tobacco products.8 An earlier
study of dual product users also reported profound levels of
tobacco dependence.19 The present study extends these previous
studies by examining these patterns in greater detail across
multiple age groups and modes of data collection.
There are several limitations inherent in the use of the datasets analysed for this study. First, all of the studies used crosssectional designs, which limits the ability to examine longitudinal patterns of transition between usage of tobacco products.
Differences in patterns of dual use between young people and
adults may reflect birth cohort effects, and future patterns of
tobacco use among adults may differ as today’s young people
progress through life. In addition, all surveys, with the exception
of NHANES, rely only on self-report to estimate prevalence and
consumption of tobacco products. Self-reported levels of tobacco
consumption may be prone to error.20e22 However, such
measurement error would be expected to be non-differential with
respect to use of other tobacco productsdfor example, we have
no reason to believe that smokeless tobacco users would differ
from non-users in the accuracy of the their reported daily cigarette consumption. Non-differential measurement error would
tend to attenuate the strength of association between smokeless
tobacco use and cigarette smoking.
In conclusion, analyses of data from four nationally representative surveys indicate that dual use of cigarettes and ST is
relatively common among young males. The pattern is different
among adult males, among whom daily smoking predominates
and non-daily snuff use is very strongly associated with current
smoking. Adult male smokers who also use snuff tend to have
relatively high levels of serum cotinine and high prevalence of
a major indicator for tobacco dependence. The major US cigarette companies now control nearly the entire US smokeless
tobacco market and aggressively promote dual product use,
which may portend a lessening in the decline in smoking,
increased dual use, perpetuation of dependence and continued
high levels of tobacco related death and disease.
What this study adds?
This study found that the prevalence of daily smoking is very
high among male students in middle school and high school who
use smokeless tobacco. The prevalence of smoking is generally
quite high among adult males who use snuff on a less-than-daily
basis and among former snuff users, while the prevalence of
smoking is relatively low among men who used snuff every day.
The study also found that adult male daily smokers who also use
snuff on some days expressed greater interest in quitting
smoking than other groups but were more likely than any other
group to have had unsuccessful quit attempts in the preceding
year. Although male dual daily users tend to smoke fewer
cigarettes per day than male daily smokers who do not use snuff
or use it less than daily, they tend to have the highest levels of
serum cotinine and exhibit among the most prevalent indicator of
dependence. The association between smokeless tobacco use
and cigarette smoking is complex, and aggressive marketing of
moist snuff by cigarette manufacturers may lead to unpredictable and undesirable public health outcomes.
Acknowledgements The authors wish to thank the reviewers for their helpful
suggestions on an earlier version of this manuscript.
Funding This study was supported by National Cancer Institute grant R01CA87477
(GNC, principal investigator).
Competing interests SLT serves as an expert witness for plaintiffs in product litigation
brought against cigarette and smokeless tobacco manufacturers.
Ethics approval This study was approved by the institutional review boards of Harvard
University and the University of Florida Health Science Center.
Contributors All authors included on this paper fulfil the criteria of authorship. We also
confirm that there is no one else who fulfils the criteria but has not been included as an
author.
Provenance and peer review Not commissioned; externally peer reviewed.
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